Familial Hyper Cholesterolemia - Next steps & Other things to do

Medical Q&A [Moderated]
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Hi docs,

Looking for other options and trying to determine if there’s anything else that I can do to move my levels back into a “normal” range. I’ll just bullet point everything out that I’ve done so far:

  1. Genetic component comes from mom’s side (she found out after I mentioned that mine was high 3 years ago, hadn’t seen a doctor in ~10 years). Dad is also on cholesterol meds (lipitor) but is significantly overweight, his levels are now under control. Both are in medicine so I was kind of surprised they didn’t look at this stuff.
  2. I’m 38 year old male, training consistently for 10+ years, have been following BBM templates for the last 2ish years. (increased emphasis on cardio aspect of GPP the last year & increased steps/day). Just finished strength 3 last month, focusing on slightly higher volume with powerbuilding 2, increasing the gpp component a bit.
  3. I cut out most dietary sources of cholesterol after my physical in Feb 2020 (red meat, eggs, cheese, etc) and have added non-animal sources for fats (nuts, EVOO, etc). I’ve been 80-90% compliant with this. Diet prior to that was higher in animal saturated fat (beef, bacon, etc).
  4. Used an app to macro track and have lost 20+lbs since the end of October (218 end october → 195 early march). Currently taking a maintenance phase to just chill out mentally, plan on losing another 10 lbs later this year. Waist is down from ~39" to 35". (rp diet app so mostly low fat, high lean protein, a lot of veg/whole grains)
  5. Fiber increase from 20ish per day, up to 40-50/day consistently (fruits/veg/whole grains/nuts, etc).
  6. At my physical over the last few years, cholesterol has come up as the main issue. It was ~250 total last year (40HDL). Had a non-fasted finger poke test at work a month ago (270 total, 43 hdl). I think I expected it to go down after being very consistent with the diet/weight loss/etc.
  7. Heart scan 2 years ago had a 0 value (i don’t remember what this measures, but it was cheap so i did it)

Met with my primary care last week. I asked if there was pharmaceutical help that we could start so I’m on 10mg/day lipitor. Followup blood work in 2 months. I’m planning on just maintaining my weight here until mid-June after our covid postponed wedding reception.

My question for you is: what else can I do in the interim between now and my blood test in may to try to drive my cholesterol numbers lower? Just stay the course with what I have been doing and cross my fingers that the meds do their job? I think I’ve checked most of the boxes aside from becoming a vegan.

This is incredibly frustrating.

Pete

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Hi Pete,

Sorry to hear about your frustrations here. It sounds like you’ve done an excellent job so far of attacking as many of the lifestyle targets as you can, specifically including the waist measurement, ratio of saturated to polyunsaturated fat intake, and dietary fiber. However, in your current situation, a non-HDL-C of 227 mg/dL (270 minus 43) is high enough that I would also suspect a degree of genetically-mediated familial hypercholesterolemia.

While it can be frustrating to put as much effort into lifestyle as you are doing and see these results, that is simply the reality of genetic predisposition. Aside from going vegan as you mention, a few things I noticed weren’t mentioned in your habitual dietary intake were 1) oily fish like salmon; incorporating 1-2 servings of this per week in place of some other animal protein may also be helpful, as well as 2) incorporating some legumes (e.g., lentils, chickpeas, beans, etc.) as fiber+protein+carb sources.

I presume the “0 value” you mention is a coronary artery calcium score; this is excellent and provides a fair amount of reassurance as far as your cardiovascular risk in the short-to-medium term. On the other hand, since you’re still very young, and cardiovascular risk accumulates over the course of a lifetime, addressing the lipids early (as you are currently doing) is probably wise. If I were in your situation I would also be using the medication to address the residual risk. When you say “cross my fingers the meds do their job”, I think it suggests a bit of unnecessary worry – there are multiple medication options across a variety of dose ranges (10 mg of atorvastatin is a super low dose); one way or another, you CAN get this under control.

1 Like
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Thanks, Dr. Baraki,

“Cross my fingers” was just poor phrasing, I think I’m hopeful (i.e. crossing my fingers) that it will be on the higher percentage range of what the literature suggests as a typical outcome from medication.

I’ll incorporate the dietary changes you recommend up above. I infrequently go for something like smoked salmon since I’m located in Colorado and “fresh” fish is harder to come by. I’ll make it a more consistent part of my routine.

I’ll followup on this after I see results mid-May.

Thanks again! Really do appreciate all that you guys are doing.
Pete